Shoulder Hurts? Start Here.

Written on May 16, 2011 at 7:45 am, by Eric Cressey

As you can probably imagine, given that I deal with a ton of baseball players – and the fact that I’ve written about shoulder pain a ton over the past decade – a lot of people initially come to Cressey Performance because their shoulder hurts. It might be rotator cuff pain, AC joint irritation, or any of a host of other issues, but you’d be surprised at how many similarities there are among the ways that you address most of these issues.

The problem is that pain can throw a wrench in your plans and limit you in your ability to get to exactly where someone needs to improve movement-wise. For instance, you might have someone who has a significant glenohumeral (ball-and-socket) internal rotation deficit, but it’s hard to manually stretch them into internal rotation without further irritating a cranky AC joint. Or, someone with a partial thickness rotator cuff tear may be dramatically limited in shoulder flexion, but even shoulder flexion with assisted scapular posterior tilt and upward rotation exacerbates their symptoms. Very simply, you can’t just pound round pegs into square holes when it comes to dealing with a delicate joint like the shoulder – and that applies to both asymptomatic and symptomatic shoulders.

To that end, there are three initiatives that I think are the absolute most important places to start in just about every case.

First, I’m a huge advocate of soft tissue work with a skilled manual therapist. In our office, we have a massage therapist and chiropractor who performs both Active Release and Graston. And, we make sure that any physical therapist to whom we refer clients uses manual therapy as an integral part of their treatment approach. Whether you’re a regular exerciser or not, tissues can get dense, nasty, and fibrotic, and integrating some hands-on work on the pec minor, posterior rotator cuff, lats, scalenes, sternocleidomastoid, and several other areas can dramatically reduce an individual’s symptoms and improve range-of-motion instantly – and that allows us to do more with a corrective exercise program.

The second area where you really can’t go wrong is incorporating thoracic spine mobilizations. The thoracic spine has direct interactions with the lumbar spine, rib cage, cervical spine, and scapulae; as a result, it has some very far-reaching effects. Unfortunately, most people are really stiff in this region – and that means they wind up with poor core and scapular stability, altered rib positioning (which impacts respiration), and cervical spine dysfunction. Fortunately, mobilizing this area can have some quick and profound benefits; I’ve seen shoulder internal rotation improve by as much as 20 degrees in a matter of 30 seconds simply by incorporating a basic thoracic spine mobility drill.

That said, not all thoracic spine mobility drills are created equal. Many of these drills require the glenohumeral joint to go into external rotation, abduction, and horizontal abduction in order to drive scapular posterior tilt/retraction and, in turn, thoracic spine extension and rotation. If you’ve got a cranky shoulder, this more extreme shoulder position usually isn’t going to go over well. So, drills like the side-lying extension-rotation are likely out:

For most folks, a quadruped extension-rotation drill will be an appropriate regression:

And, if the hand position (behind the head) is still problematic for the shoulder, you can always simply put it on the opposite shoulder (in the above example, the right hand would be placed on the left shoulder) and keep the rest of the movement the same.

Last, but certainly not least, you can almost always work on forward head posture from the get-go with someone whose shoulder hurts. We start with standing chin tucks, and then progress to quadruped chin tucks.

Additionally, working on cervical rotation is extremely valuable, although teaching that is a bit beyond the scope of this post.

Keep in mind that these three broad initiatives are really just the tip of the iceberg when it comes to a comprehensive corrective exercise plan that would also include a focus on scapular stabilization and rotator cuff exercises, plus additional mobility drills. They are, however, safe entry-level strategies you can use with just about anyone to get the ball rolling without making a shoulder hurt worse in a strength and conditioning program.

For more information on what a comprehensive shoulder rehabilitation program and the concurrent strength and conditioning program should include, check out Optimal Shoulder Performance, a DVD set I co-created with Mike Reinold, the Head Athletic Trainer and Rehabilitation Coordinator of the Boston Red Sox.

The Optimal Shoulder Performance DVD is a phenomenal presentation of the variables surrounding shoulder health, function, and performance. It combines the most current research, real world application as well as the the instruction on how to implement its vast amount of material immediately. After just one viewing, I decided to employ some of the tactics and methods into our assessment and exercise protocols, and as a result, I feel that myself, my staff and my clients have benefited greatly.
Michael Ranfone BS, CSCS, LMT, ART
Owner, Ranfone Training Systems

As someone who played sports until after college I often find my self pushing my limits. This introduced me to a popping noise and a sharp bit of pain when my fork was compromised and my elbows flared during the bench press.
I know quite a few online and offline that suffer from this shoulder injury.
It is very difficult to recover from as even basic movements are met with pain and popping
This is a subject I would love for you to address for all of us following you that have this problem.
Ryan

I really think PTs focus way to much on scapular stabilization exercises for lower trap and serratus anterior as weel as for exercises to strengthen the rotator cuff muscles. How will this help you if your ribcage is flared, you can´t use your diaphragm to breathe properley and you have the posture of a Neanderthal.

Cressy hits the head on the nail with this one, adress thorarcic mobility, forward head posture ABD breathing pattern and I think the other issues takes care of them self.

Ive bought just about all of Erics stuff and I gotta hand it to him: its all fantastic work. This DVD is absolutely essential for people who want to train atletes and my knowledge on the area increased greatly after viewing the dvds.

Interesting stuff as I am currently working with some of the GB paratriathlon squad who use handbikes for 20km and racing chairs for the final 5km.
Any specific mobilisation for these guys who have limited TSpine function?

Thank you for publishing this. I have had intermittent left shoulder pain for the last month and, since I couldn’t determine what I’d done to cause the pain, I was getting rather frustrated with it. I tried the exercises demonstrated here and had immediate relief of the pain and increased ROM without pain. I know the issue isn’t completely solved and I’d benefit from the DVD, but I’m incredibly grateful just to have some relief. Thanks again.

Having come back from an extended lay-off from training (bit of an understatement, as it’s been ten years!), I have found that I can’t do press-ups and bench press etc without inducing shoulder pain(lot of popping/pain around the coracoid process extending down towards the bicep area). Pulling movements aren’t a problem.

As I’ve had a computer based job for the last 10 years, my posture is terrible. Reading the information on this site, would I be better off concentrating on pulling movements and working on postural issues, dropping pushing movements altogether?

As a Chiropractor myself, I’d be interested in learning more about how you incorporate the chiropractic adjustments into the athlete’s programming. You mentioned mobilization of the thoracic spine but never really dove into manual therapy specifics. Does this include adjustments at your facility? I am an ART provider and I am a regular on your friend Dr. Brady’s Integrative Diagnosis forum, so this stuff is right up my alley, and I’m interested in your experience with integration of Chiropractic care with high level athletes.

To add to the self-myofascial release info, I’ve had tremendous success with clients by working out hot spots on their supra and infrapinatus (as you mentioned for a therapist to do).

Rolling out the infraspinatus with a lacrosse ball against the wall, and using a golf ball or small bouncy ball on the supraspinatus (it’s tougher to hit), has provided immediate shoulder relief for many clients.

Then of course, we need to address the other issues so the trigger points don’t return!

Eric,
What rehab can you recommend for a patient with pain in supraspinatus and long biceps tendon area after any press variations? It seems like he can’t live without bench press and shoulder presses:)